Provider Demographics
NPI:1124053699
Name:DORTA-DUQUE, JORGE J (MD)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:J
Last Name:DORTA-DUQUE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 CRUMP RD
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-9279
Mailing Address - Country:US
Mailing Address - Phone:863-242-7512
Mailing Address - Fax:
Practice Address - Street 1:1800 MERCY DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32808-5646
Practice Address - Country:US
Practice Address - Phone:863-242-7512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00568822084P0804X
FLME568822084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL055252600Medicaid
FL055252600Medicaid
FLE-94368Medicare UPIN